A Cross-Sectional Study on Knowledge, Attitude, and Practices of Donning and Doffing of Personal Protective Equipment: An Institutional Survey of Health-Care Staff during the COVID-19 Pandemic.

BACKGROUND: Personal protective equipment (PPE) is used to protect the health-care professional from bacterial, viral, or other hazards during this COVID-19 pandemic, and they should be made aware of proper usage of this equipment. AIMS: The aim was to evaluate how adequate knowledge, attitude, and practices (KAP) of health-care worker toward the appropriate use of PPE, which can prevent them and the community from virus contamination.
METHODOLOGY: This study was conducted in a tertiary care hospital during the COVID-19 pandemic in a span of approximately 50 days. This cross-sectional questionnaire-based survey was done in 155 health-care providers posted in the COVID-19 area. STATISTICAL ANALYSIS: Data were described in terms of range; mean ± standard deviation, frequencies (number of cases) and relative frequencies (percentages) as appropriate.
RESULTS: Health-care workers (HCWs) were aware of the importance and criticality of donning and doffing procedure, but they lack the knowledge about dispersion of virus as 62% responded that virus dispersion occurs more during donning than doffing. Gaps were found in attitude as 51% of HCWs found it inconvenient to don PPE that they sometimes think of compromising their own safety. Nearly 33.5% of HCWs move out of the doffing area without removing gloves and N-95, which needs serious correction in their practice.
CONCLUSION: There were major gaps in KAP at institutional level among the health-care providers with regard to donning and doffing of PPE during the beginning of this pandemic. Copyright:

INTRODUCTION

Personal protective equipment (PPE) is a protective gear designed to safeguard the health of workers by minimizing the exposure to a biological agent. PPE usage is a primary strategy to prevent disease transmission in health-care settings where health-care professionals directly come in contact with infected patients. Kang et al. discovered that health-care personnel contaminated themselves in almost 80% of the PPE simulations.[1] A number of organizations have produced guidance on PPE, which is broadly consistent, including the World Health Organization;[2] the European Centre for Disease Control;[3] and the European Society of Intensive Care Medicine and Society of Critical Care Medicine. A recent study in the UK and the USA estimated that frontline health-care workers had a 3.4 fold higher risk than people living in the general community for reporting a positive test.[4]

Different types of PPE are used which include coveralls, gowns, hoods, masks, goggles, and face shields, to prevent the wearer's skin and mucous membranes from becoming contaminated, and respirators to prevent them inhaling infected particles.

All the three aspects of donning and doffing, that is, knowledge, attitude, and practices (KAP), are important to completely understand and analyze the behavior of health-care workers (HCWs). Knowledge shows individual's readiness to perform the behavior, attitude tells about his sincerity toward why he or she thinks that the behavior is important, and finally real-time practice while performing his duties shows how careful is the individual in practicing the desired behavior.

As cases of COVID-19 are increasing alarmingly in our country, appropriate use of PPE is one of the integral strategic initiatives to prevent COVID-19 infection in a health-care facility of any size and scale. One of the most ignored but critical aspects of PPE by most researchers is that does our HCWs use these PPE kits properly without self-contamination?

Interim guidance on the rational use of PPE for COVID-19, issued by the WHO on March 19, 2020, categorically reiterated on “correct and rigorous behavior from all the health-care professionals” especially while doffing these PPE kits. In a study, HCWs found PPE usage as a cumbersome process during their practice though they believed in its effectiveness.[1]

Few studies have evaluated these practice and behaviors of PPE use in settings of routine clinical care such as hospitals and nursing care centers.[56] A study conducted in the early 2000s SARS outbreak reported that recommendations related to the usage of PPE were discordant and only few HCW were well acquainted with its correct usage and the way to avoid contaminating themselves.[6]

This acceptance to adapt to the new normal may stem from the lack of safety resources, lack of knowledge about resources, lack of attitude to use safety resources, and lack of training to practice use of these resources.

Practicing any behavior is not easy if a person does not have correct attitude toward it. Furthermore, attitude toward any practice has no utility if a person is not having correct and actionable knowledge about how to carry out the practice. This is the main compelling reason for conducting this KAP survey on donning and doffing practices of PPE amidst the ongoing COVID-19 pandemic to identify and understand the gaps and develop an intervention strategy to improve the knowledge level, attitude, and behavior of HCWs on donning and doffing practices of PPEs.

METHODOLOGY

This is a cross-sectional survey on KAP of donning and doffing techniques conducted in a tertiary care hospital form April 10, 2020, to May 30, 2020, that is for a period of approximately 50 days, amidst the ongoing COVID-19 pandemic. The KAP tool was scientifically designed considering all required validations including statistical precautions and guidelines. A questionnaire was developed in English as shown in [Annexure 1] and then translated into local vernacular language to make it more versatile for regional staff members.

Annexure 1

Knowledge, attitude, and practices survey questionnaire

Knowledge
Statement	Yes	No	Not always
Do you know donning and doffing of PPE practices for health-care professionals?	Yes	No	Not always
Have you received any formal “training or demonstration” regarding donning and doffing of PPE kits?	Yes	No	Not always
Do you know the complete procedure of donning and doffing of PPE in health-care facility?	Yes	No	Not always
Do you know all the components of PPE kits used in your facility?	Yes	No	Not always
Do you understand the sensitivity and importance of donning and doffing?	Yes	No	Not always
Are you aware that virus dispersion occurs more commonly during doffing	Yes	No	Not always
Attitude
Statement	Yes	No	Not always
Do you think donning and doffing of PPE is a critical process that must be taken seriously by health-care professionals?	Yes	No	Not always
Do you follow strictly the methodical way of donning and doffing of PPE?	Yes	No	Not always
Do you think donning and doffing practices are more hyped than it should be especially in COVID-19 areas?	Yes	No	Not always
Do you find it inconvenient to care for your patients after donning, that you think of letting go your safety guard?	Yes	No	Not always
Do you think, donning and doffing is more important only when posted in COVID-19 area otherwise it is not of much value?	Yes	No	Not always
Do you think your facility is adequately equipped with all resources and space required for methodical donning and doffing practices?	Yes	No	Not always
Do you think if other health-care workers/colleagues working in same area are not following proper procedure of donning and doffing of PPE, it affects your behavior also?	Yes	No	Not always
Do you agree that strict donning and doffing practices would wear off if the pandemic continues for a very long period of years?	Yes	No	Not always
Practices
Statement	Yes	No	Not always
In this ongoing COVID pandemic, do you do donning/doffing in all COVID-suspected patients?	Yes	No
Do you do donning/doffing in all patients undergoing any surgery or airway related procedures?	Yes	No
Which of the following instructions do you follow before donning PPE kits?
Get enough water intake to remain hydrated	Yes	No	Not always
I always get all my jewelry/mobile or other personal belongings removed	Yes	No	Not always
I always wash/sanitize my hands, before touching any PPE component	Yes	No	Not always
Which of the following things you do during donning procedure of PPE kits?
I always perform donning procedure before entering the patient’s room	Yes	No	Not always
I always visually check the integrity of the components of PPE kits before donning procedure	Yes	No	Not always
Can I move out of patient care area after donning PPE?	Yes	No	Not always
I always put the gown first before putting the first pair of gloves	Yes	No	Not always
I use respirator or N-95 mask followed by eye goggles/face shield	Yes	No	Not always
Which of the following things you do during doffing procedure of PPE kits?
I always appoint an observer with checklist while performing doffing procedure to avoid breach of technique	Yes	No	Not always
Should there always be a specified doffing area in all patient care complexes?	Yes	No	Not always
I always remove gloves first during doffing procedure using glove-in-glove technique without sanitizing the gloves	Yes	No	Not always
I remove gown after removing inner pair of gloves	Yes	No	Not always
I turn the gown inside-out during removal to get the infected side packed inside of gown	Yes	No	Not always
I move out from the doffing area after removal of gloves and N95 mask	Yes	No	Not always
Do I sanitize my hands/gloves before and after each step of doffing procedure	Yes	No	Not always

PPE=Personal protective equipment

Inclusion criteria were based on medical or paramedical staff on duty in COVID-19 area who have completely filled up the survey questionnaire. In case <70% questions were responded, participation was cancelled and questionnaire was not considered for further statistical analysis.

Statistical analysis

The survey population included 155 health-care professionals including doctors, nurses, and technicians posted in a COVID-19 area. Data were collected, collated, and entered into an excel sheet and statistically analyzed utilizing descriptive statistics followed by element-wise analysis of questionnaire. Data were described in terms of range: mean ± standard deviation, frequencies (number of cases), and relative frequencies (percentages), as appropriate. All statistical calculations were done using Statistical Package for the Social Science (SPSS) SPSS 21 version (SPSS Inc., Chicago, IL, USA) statistical program for Microsoft Windows. KAP sections were separately analyzed for each survey element.

Ethics statement

Finally, the tool was reviewed by the pre-assigned hospital ethics committee, and formal ethical approval with IEC number 2020-521 was taken from the institutional ethics committee to conduct this survey. A questionnaire comprising of thirty elements, divided into three sections of KAP, was circulated among the health-care professionals using the PPE and posted in the COVID-19 area. Staff were instructed on general guidelines for participation in the study. Verbal consent from the staff was taken beforehand for their participation.

RESULTS

Distribution of participants in terms of demographic variables such as age and gender was comparable. More nursing staff participated in the survey as compared to technical staff and doctors [Figure 1]. Analyses showed that 100% of the HCWs were aware of the practices of donning and doffing of PPE, with 91.6% of HCWs exhibiting complete knowledge regarding the procedure of donning and doffing of PPE. There was awareness of all components of PPE in 90.3% of the health-care providers. However, on being inquired whether virus dispersion occurs more during donning than doffing, only 31.6% of the HCWs knew that this is incorrect [Table 1].

Figure 1

Pie graph depicting the study population in the survey

Table 1

Percentage of knowledge among participants

Statement	Yes (%)	No (%)
Do you know donning and doffing of PPE practices for health-care professionals?	100.00	0.00
Have you received any formal “training or demonstration” regarding donning and doffing of PPE kits?	58.06	41.29
Do you know the complete procedure of donning and doffing of PPE in health-care facility?	91.61	7.10
Do you know all the components of PPE kits used in your facility?	90.32	8.39
Do you understand the sensitivity and importance of donning and doffing?	98.06	1.94
Are you aware that virus dispersion occurs more commonly during doffing	61.94	37.42

PPE=Personal protective equipment

On analyzing the attitudes regarding donning and doffing of PPE, 98.7% of the health-care professionals think that donning and doffing of PPE is a critical process which must be taken seriously and 83.2% of HCWs strictly follow the methodical way of donning and doffing. Still 51% of the HCWs find it inconvenient to care the patients after donning and 49.7% of the health-care professionals concurred that strict donning and doffing practices would not be possible, if this pandemic stayed for a long time [Table 2].

Table 2

Percentage of attitude amongst health-care workers

Statement	Yes (%)	No (%)	Not always (%)
Do you think donning and doffing of PPE is a critical process that must be taken seriously by health-care professionals?	98.71	1.29	0.00
Do you follow strictly the methodical way of donning and doffing of PPE?	83.23	9.03	6.45
Do you think donning and doffing practices are more hyped than it should be especially in COVID-19 areas?	57.42	33.55	8.39
Do you find it inconvenient to care for your patients after donning, that you think of letting go your safety guard	50.97	29.68	17.42
Do you think, donning and doffing is more important only when posted in COVID-19 area otherwise it is not of much value?	34.84	56.77	6.45
Do you think your facility is adequately equipped with all resources and space required for methodical donning and doffing practices?	69.03	22.58	6.45
Do you think if other health-care workers/colleagues working in same area are not following proper procedure of donning and doffing of PPE, it affects your behavior also?	61.94	30.97	7.10
Do you agree that strict donning and doffing practices would wear off if the pandemic continues for a very long period of years	49.68	39.35	7.10

PPE=Personal protective equipment

On reviewing the practices of the health-care providers, 82.6% did donning/doffing while attending all COVID-19-suspected patients and 62.6% did donning/doffing for performing surgery or airway-related procedures on all patients irrespective of their COVID-19 status. While doffing PPE, 61.9% of the health-care professionals appoint an observer or use checklist, and 88.4% suggest that there should be specified doffing area in all patient care complexes. With regard to sanitizing the hands/gloves before and after each step of doffing procedures, 90.3% of HCWs follow it strictly [Table 3]. Our survey revealed that 78.17% of HCWs had knowledge, but attitude was seen in only 58.95% [Figure 2].

Table 3

Percentage of practices amongst health-care workers

Statement	Yes (%)	No (%)	Not always (%)
In this ongoing COVID pandemic, do you do donning/doffing in all COVID-suspected patients?	82.58	5.16	10.97
Do you do donning/doffing in all patients undergoing any surgery or airway related procedures?	62.58	18.06	11.61
Which of the following instructions do you follow before donning PPE kits?
Get enough water intake to remain hydrated	76.77	13.55	8.39
I always get all my jewelry/mobile or other personal belongings removed	96.13	1.94	0.65
I always wash/sanitize my hands, before touching any PPE component	98.06	0.00	0.65
Which of the following things you do during donning procedure of PPE kits?
I always perform donning procedure before entering the patient’s room	86.45	9.03	3.23
I always visually check the integrity of the components of PPE kits before donning procedure	81.94	10.32	3.87
Can I move out of patient care area after donning PPE	36.77	54.19	3.87
I always put the gown first before putting first pair of gloves	60.00	36.77	0.00
I use respirator or N95 mask followed by eye goggles/face shield	87.74	9.68	1.29
I always appoint an observer with checklist while performing doffing procedure to avoid breach of technique	67.74	17.42	10.32
Which of the following things you do “during doffing” procedure of PPE kits?
I always appoint observer with checklist while performing doffing procedure to avoid breach of technique	61.94	20.00	15.48
Should there always be a specified doffing area in all patient care complexes	88.39	10.32	0.00
I always remove gloves first during doffing procedure using glove-in-glove technique without sanitizing the gloves	36.13	58.71	1.29
I remove gown after removing inner pair of gloves	45.81	52.26	0.00
I turn the gown inside-out during removal to get the infected side packed inside of gown	93.55	2.58	1.29
I move out from the doffing area after removal of gloves and N95 mask	61.29	33.55	3.23
Do I sanitize my hands/gloves before and after each step of doffing procedure	90.32	3.23	5.16

PPE=Personal protective equipment

Figure 2

Percentage of knowledge, attitude, and practices among health-care workers

DISCUSSION

Incorrect donning and doffing leads to viral contamination of the HCWs, who are the most valuable resource in combating this COVID-19 pandemic. Even the best designed and manufactured PPE kits may not be able to save HCWs from the potential infectious agents if they lack proper KAP practice.

Our survey revealed that though HCWs have good knowledge with regard to the importance of donning and doffing procedure of PPE, however majority of them lacked the awareness that doffing causes more virus dispersion than donning, and improper doffing is one of the main factors for viral contamination amongst HCWs, hence this needs their careful attention.

A recent study found that despite prior reviewing of the doffing protocol by Centre for Disease Control and Prevention, and having this protocol displayed in front of them, errors were common place among HCWs.[7] This reflects the importance of attitude and continuous practice over knowledge to make this process of donning and doffing of PPE safe for the HCWs.

Participants in our KAP survey reported that due to the cumbersome and time-consuming nature of donning and doffing procedure, they had an urge to compromise their own safety despite understanding the critical nature of this process. In our survey, we also found that though HCWs were ready to follow the methodical way of donning and doffing, but they still consider it a more hyped practice, which indicates an apathetic attitude perhaps due to lack of motivation.

A mixed-methods approach was used in studies to recognize different things during donning and doffing of PPE and accordingly develop a criteria and appropriate design to establish a comfortable usage of different components of PPE. Our study confirms the need for the same as majority (>67%) wanted to compromise safety due to cumbersome procedure and discomfort when wearing the PPE.[8] Many health-care providers in our study felt that their behavior gets affected when other colleagues working in the same area were not following the proper procedure of donning and doffing. Also, they expressed that strict donning and doffing practices would not be possible if this pandemic stays for a very long time. This type of attitude needs to be modified with reinforcement of proper techniques as studies have shown that 46%–90% HCWs self-contaminate routinely during doffing.[910]

Reiterating that preservation is obtained via a thorough familiarity of PPE components and their proper usage through repeated customized training is the way forward to internalize these into our attitudes.[11] Our survey echoes similar observations; we also found that knowledge about donning and doffing procedure and repeated training on same is an important part to reduce chances of self-contamination of HCWs. The gaps in doffing practices observed in our survey could also be ascribed to the absence of use of checklist or observer in majority instances. This leads to poor detection of breeches during doffing. Our survey also revealed that HCWs were following incorrect sequences of doffing such as removing gown after removing inner pair of gloves. A study by Poller et al. also found that HCWs resorted to practices such as removing their robes and gloves by sweeping them against their previously uncontaminated clothes prior to discarding. These faulty doffing practices of PPE may be due to an incognizance, time constraints, or lack of realization of the importance of proper PPE removal.[12] Our study also found similar claims related to time, awareness, and gaps in understanding the importance of the procedure.

A study from South Korea highlighted that during PPE doffing, the most vulnerable processes were removal of respirator, shoe cover, and hood.[13] However, in our study we have not captured this aspect as this needs direct observation and cannot be justified in a survey.

Studies have observed deviations from the recommended procedure during donning and doffing as HCWs got confused with various types of PPE underpinning the need to standardize the type of PPEs and procedure both.[14] In our study, we have kept a single type of PPE throughout the pandemic, which is helpful in standardized gaps in practices by HCWs.

CONCLUSION

Overall, we may summarize this survey as an assisting insight generator getting us familiar with the major gaps in knowledge, attitude and practices existing at the institutional level, that could be addressed by mentoring, training, inculcating habits of good medical practices that may require designing in-house training programs, and using digital techniques and technology to keep better monitoring during critical procedures and keep guiding the users on these critical but important routine procedures, which will lead to reduced incidence of contamination during pandemic times like COVID-19.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.